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Potter, Robert 9 ©3 NEW YORK STATE DEPARTMENT OF HEALTH' % Vital Records Section Burial - Transit Permit • Name First Middle Last Sex Robert R. Potter Male Date of Death Age If Veteran of U.S. Armed Forces, December 16, 2016 96 War or Dates • Place of Death Hospital, Institution or g City, Town or Village Glens Falls Street Address The Pines Of Glens Falls Manner of Death ❑ n n Undetermined n Pending }€ Natural Cause Accident Homicide Suicide Circumstances Investigation Medical Certifier NamewaoHoy i I rkm/. Address * v t� ( a cof ' Death Certificate Filed Distric NumberaDy Register b cr.) } City, Town or Village ❑Burial Date Cemetery or Crematory December 19, 2016 Pine View Crematorium ❑Entombment Address ®Cremation 51 Quaker Road, Queensbury, NY 12804 Date Place Removed Z Removal and/or Held and/or Address H Hold Cl) 0 Date Point of es ❑Transportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address El Reinterment Date Cemetery Address gi Permit Issued to Registration Number LS Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 % Address �rrr ` 407 Bay Road, Queensbury, NY 12804 wi ..{ Name of Funeral Firm Making Disposition or to Whom ' Remains are Shipped, If Other than Above Address 1x • Permission is hereby granted to dispose of the human remains de rib d a ove i dicated. fff {,,;,, Date Issued ,/ /. /6 Registrar of Vital Statistics e r.r >,<.:: (signature) r r District Number c56Ql Place CG�t.+s- 3 A /u7 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z alDate of Disposition /Zh//G Place of Disposition ) , *_v,."Z!,,�./ Cf _n.r‘k ry 111 / (address) CO piY (section) /(lot number) (grave number) Name of Sexton on in Charge of Premises i� �re— 1 ( yr i, 2 e (please print) W `� Signature . , `7 zf ik' `---- Title �.re - rze .4,' (over) DOH-1555(02/2004)